Exploring the history of hospital infections
from early pioneers in hospital cleanliness to the rise of the so-called
'Superbugs'.

by Thomas Dormandy

In the Crimean War
patients admitted to Florence Nightingale's legendary field hospital
in Scoutari were significantly less likely to survive than those
taking part in the Charge of the Light Brigade. The comparison though
is of course a statistical outrage. Most of those admitted to the
hospital in Scoutari were already dying from infected wounds, blood
loss and exposure or, most commonly, a combination of all three.
Their chances of survival were probably better than if they had
been left to rot on the battlefield (as tens of thousands were).
Yet hospitals in the mid nineteenth century were undoubtedly dangerous
places where patients expected to die and mostly did.

The change, when it
came, was largely the achievement of a few remarkable individuals.
(The politically correct notion that great medical advances are
the products of team work is a modern figment.) Among the pioneers,
was a young Hungarian doctor called Ignác Semmelweis who,
in 1846, found himself working as a junior assistant in the Midwifery
Department of one of Europe's most prestigious hospitals, the Allgemeines
Krankenhaus of Vienna. Prestigious but also dreaded among the young
women of the Imperial Capital. At times 1 in 5 healthy young mothers-to-be
admitted to give birth never left the building alive; and their
mode of death, childbed fever, usually striking within a few hours
of labour, was one of the most painful at a time when physical suffering
was commonplace. Nobody knew the cause: lunar radiations and other
lunacies were widely canvassed. The problem drove young Semmelweis
to distraction, the more so since the catastrophic mortality in
his own department contrasted with the comparatively low death rate
in the adjacent department staffed entirely by midwives.

His "moment of
truth" came on his return from a holiday when he was told that
his closest friend, Kolletschka, a forensic pathologist, had suffered
a cut finger performing a post-mortem examination and had died a
few days later from blood poisoning. The symptoms and the lesions
at his own post-mortem seemed to be exactly the same as those Semmelweis
had seen in hundreds of young women who had died in childbed fever.
Semmelweis realised that the mothers' illness was caused by infection
introduced into the open wound of the womb by doctors and medical
students, often arriving in the labour ward directly from performing
post-mortem examinations in the mortuary. Midwives did not perform
post-mortem's: hence the lower mortality in the midwives' ward.
To clinch the evidence, the introduction of thorough scrubbing of
hands with carbolic acid before entering the labour ward, slashed
the incidence of childbed fever.

Semmelweis was a short-tempered
and inpatient foreigner in the hierarchical setting of Imperial
Vienna. When the hidebound obstetric establishment failed to be
convinced by what seemed to him the "blazing truth", he
threw up his job and returned to his native Pest (today's Budapest).
From there he dispatched a stream of open letters to the leading
but benighted obstetricians of Europe, telling them that they themselves
were responsible for millions of young mothers dying unnecessarily
and comparing some of them unfavourably to Nero. This was ill received.
Eventually he was declared insane and lured to a lunatic asylum
in Vienna. During a scuffle as he was put into a straightjacket,
he cut his finger. Ten days later he was dead himself from blood
poisoning.

It is uncertain if
Semmelweis's beloved doctrine of cleanliness would ever have prevailed
without the brilliant work of the English surgeon, Joseph Lister.
By the 1860s epidemics of "hospital sepsis" both in Britain
and on the Continent were becoming catastrophic. Those outbreaks
killed not only patients but also hospital staff and even visitors.
It was seriously suggested in Parliament that all hospitals in Britain
should be closed to be replaced by hutted encampments in open spaces
like Hyde Park and the New Forest. Lister, the scion of an English
Quaker family, was at that time professor of surgery in Glasgow.
His "moment of truth" came when a colleague, a professor
of chemistry, drew his attention to the work of the French chemist
Louis Pasteur. Pasteur had discovered - and had indeed demonstrated
beyond doubt - that the atmosphere was teeming with millions of
invisible but living "germs". An inspired piece of lateral
thinking convinced Lister that if these "germs" could
spoil wine and sour milk, they could also be responsible for wound
infection and hospital sepsis. He proved his idea by eliminating
germs using a device known as the antiseptic spray. This was like
a giant insect spray but containing an antiseptic fluid. It enveloped
the operating theatre in a highly irritating cloud of vapour; but,
for the first time, open fractures, which used to be inevitably
fatal unless the limb was immediately amputated, healed without
infection and without causing general blood poisoning.

Credit Moody Medical Library

Joseph Lister,
1827-1912

Unlike Semmelweis,
Lister was part of the Victorian establishment, surgeon to the Queen
(if only in Scotland), a man on friendly terms with some of the
leading doctors of his day. Even so, it took him the best part of
thirty years to convince his colleagues that germs were real, that
they caused wound infections and that they could be eliminated.
His doctrine which he called antisepsis was more readily embraced
on the Continent, especially in Germany. It was adopted by the great
surgeon Billroth in Vienna, though he continued to operate smoking
a giant cigar.

Together with anaesthesia,
introduced more or less at the same time. Antisepsis transformed
surgery from skillful butchery, severely limited in scope to the
limbs and superficial lesions, into a craft, art and science. No
part of the body was now inaccessible. Children with acute appendicitis
and adults with perforated ulcers no longer inevitably died. Lister
lived long enough to become the first surgical peer, president of
the Royal Society and, in 1901, founding member of the Order of
Merit. Ironically, by then, antisepsis was giving way to a new and
more radical approach to combatting hospital infection, a change
which Lister himself deplored.

If surgery could be
rendered comparatively safe by killing noxious germs, how much safer
would it be if germs were never allowed near wounds in the first
place? The answer was the doctrine of asepsis, as distinct from
Listerian antisepsis. Gowns, masks, caps, rubber boots, the thorough
and prolonged scrubbing of hands preliminary to the donning of rubber
gloves and filtered air in the operating theatre made Lister's carbolic-acid
spray obsolete. Asepsis was brilliantly successful and remained
unchallenged until the 1950s.

Many medicines
are produced with the help of fungi, most notably, the antibiotic,
Penicillin.

In the 1950s, the advent
of penicillin inaugurated the age of antibiotics, seemingly the
final triumph over hospital sepsis. So effective were the new wonder-drugs
in the few cases of infection which still occurred that in the 1960s
some eminent and otherwise sane surgeons began to advocate that
all patients admitted for surgery should be routinely started on
antibiotics and kept on "antibiotic cover" while in hospital.
This was madness, a return to Listerian antisepsis in a new and
more dangerous guise. (Medical history would be an arid subject
if human folly did not continually resurrect past situations.)

The doctrine never
received official blessing; but the profligate use of antibiotics
ruled and was inevitably accompanied by a relaxation of aseptic
and even of basic hygienic precautions. The day of the new super-bug
had arrived...

These superbugs are
in fact neither new nor particularly super. Staphylococci were described
by Pasteur 150 years ago: the hybrid term means berries in a bunch
to distinguish them from streptococci which are berries in a chain.
Thousands of different strains exist, most of them harmless inhabitants
of the human nose, throat and skin. The dangerous strains were among
the first successful targets of penicillin. When penicillin stopped
being effective, other antibiotics came along. The trouble is that
the survival of the fittest operates among invisible microbes even
more effectively than it does in the visible world. Whether by adaptive
selection or by genetic mutation, it is a fair guess that resistant
strains will eventually be bred to every new antibiotic. Microbes
have existed for millions of years before homo sapiens. They are
likely to survive the species by many more million years. Of course,
it is the micro time of decades and centuries which matters to us.

Predictably, the place
where resistant organisms are selectively bred first and most effectively
are hospitals. This was so long before micro-organisms were thought
of; but it has become more critical with the advent of antibiotics.
Age and illness makes the hospital in-patient population exceptionally
susceptible to infection. Hospitals have been permeated with antibiotics
for fifty years. Nurses and doctors continually move between patients,
spreading resistant organisms unless a few elementary precautions
are taken. These were second nature fifty years ago. They are no
longer. (Watch next time you are in a hospital.)

Today more than 5000
patients die prematurely every year in England from multi-drug-resistant
organisms. (The current technical acronym is MRSA's or, for the
more severe form, VRSA's.) The figures are rising and rising at
an increasing rate. Where will it all end? As in Semmelweis's and
Lister's days, informed opinion is divided. Some doctors tacitly
think that the menace is exaggerated. Others even more discreetly
suspect that, even if not exaggerated., nothing can be done about
it. Hospitals have been dangerous places for centuries. After a
pleasant but short lull, they will become dangerous places again.
Others believe, some passionately, that the danger can and should
be eliminated. Patients will always die. They should not die of
a disease they catch in hospital.